Patient, Public & Media Information

Symposium Explores Outpatient TJA, Spine Procedures

Experts emphasize
using a comprehensive approach to achieve positive outcomes

“When I started talking about doing outpatient total
joint arthroplasty (TJA) 15 years ago, everyone looked at me like I was crazy,”
said Richard Berger, MD. Since then,
Dr. Berger has performed thousands of successful outpatient primary hip and
knee arthroplasty procedures. In his view, surgery is only one part of the
equation for achieving good patient outcomes with outpatient TJA. To achieve
rapid rehabilitation, he said, a synergistic approach must be employed that
combines various elements, including patient education, minimally invasive
surgery, effective pain management, and rehabilitation.

Richard Berger, MD,
discusses outpatient total joint arthroplasty during a symposium held Tuesday.

During a symposium moderated by Adolph V. Lombardi, Jr, MD, FACS, and held at the AAOS Annual
Meeting on Tuesday, Dr. Berger and other experts focused on strategies for
performing outpatient surgeries safely and effectively, with the goal of
maximizing patient satisfaction and reducing healthcare costs.

Outpatient TJA protocolAccording to Dr. Berger, his institution’s protocol for outpatient TJA
begins with preoperative patient education that addresses surgery, recovery,
and discharge. Patients’ postoperative care and services are also addressed, as
are special needs and concerns. Prior to surgery, patients are evaluated by an
internist and checked for contraindications to same-day discharge.

Prior to surgery, with some exceptions, patients receive
a COX-2 inhibitor, pregabalin, preoperative opioids, and a scopolamine patch.
During surgery, an epidural anesthetic is used, while sedation and other agents
are minimized.

“Because we use minimal anesthesia, the patients are
moving a little bit,” explained Dr. Berger. “It’s a little harder to do the
surgery, but it’s better for the patient.”

In the recovery room, patients may receive other
medications, depending on their age and previous opioid use.

“We give patients an anti-inflammatory medication and
pregabalin for a couple weeks,” said Dr. Berger. “Some patients get up and walk
right away with little assistance, but we give them a cane to take home if they
want one.”

Surgery is followed by 3 to 4 weeks of outpatient
therapy.

Anesthetic
techniques, controlling pain According to Craig J. Della Valle,
MD, goals related to anesthesia in an outpatient setting include optimizing
pain control while minimizing side effects such as nausea and lower extremity
weakness, with a focus on rapid mobilization and early, safe discharge.

“In addition,” said Dr. Della Valle, “pericapsular
injections have been shown to be helpful in several randomized trials.”

Like Dr. Della Valle, Michael J. Morris, MD, emphasized the importance of preemptive and
multimodal anesthesia, which he noted “provides a synergistic benefit for our
patients while minimizing undesired side effects.”

Dr. Morris cited a randomized, controlled study of 64
total knee arthroplasty (TKA) patients divided into two groups: one that
received a periarticular injection with ropivacaine, ketorolac, epimorphine,
and epinephrine, and a control group that received no injection at all, with
patient-controlled analgesia standardized for both cohorts.

“The periarticular injection group had significantly less
pain at 6 hours, 12 hours, and 24 hours, had less opioid consumption, and were
more highly satisfied,” said Dr. Morris.

In another study—a double-blind, randomized controlled
trial of 80 primary TKA patients—researchers studied the effects of
periarticular injections with the aforementioned types of medications versus
normal saline and found less opioid consumption and pain, and higher patient
satisfaction in the periarticular injection group.

Blood managementBlood management is another important consideration for outpatient
procedures, noted William G. Hamilton,
MD.

“For outpatient TJA, you really need to eliminate or
radically reduce your transfusion rate, not just for patient safety, but for
shortening the length of stay,” he said. Noting that there is no access to
blood products at many surgery centers, Dr. Hamilton asserted that, prior to
performing TJA in a surgery center, an orthopaedic surgeon’s transfusion rate
should be well below 5 percent.

“Preoperatively, it is important to check the patient’s
hemoglobin level,” he said. “We know that one of the most important predictors
of postoperative transfusions is the preoperative hemoglobin level. All
patients get an iron supplement, because my goal is to have the hemoglobin as
high as possible in these patients.”

For patients with lower hemoglobin levels, Dr. Hamilton
considers postponing surgery or moving them to the main hospital where a blood
transfusion would be possible. In addition, he evaluates for risk factors that
have been shown to increase blood loss, such as advanced age and multiple
comorbidities. He warned that some patients—such as very thin, female
patients—do not have the same blood volume as others, which can make them more
prone to requiring a transfusion.

“Tranexamic acid is no longer a new issue; I think we’re
all using it,” said Dr. Hamilton. “It can be given intravenously using a
weight-based protocol, or a standardized dose can be given to all patients.”

Dr. Hamilton acknowledged that there has been some
concern that using tranexamic acid could increase the risk of venous
thromboembolism (VTE). He cited one study involving more than 13,000 patients
who underwent elective total hip arthroplasty (THA) and TKA. At 30-day
follow-up, noted Dr. Hamilton, the researchers found no increased risk of VTE
or death.

Another large study of TJA patients found no difference
in symptomatic VTE in patients who received tranexamic acid compared to those
who did not.

In summary, he said, if preoperative, intraoperative, and
postoperative techniques for reducing blood loss are followed, “transfusion
rates can be reduced to a negligible number.”

Outpatient lumbar
fusion
Daniel S. Husted, MD, discussed performing lumbar fusion at an ambulatory
surgery center, noting that patient selection is an important factor, as is
using appropriate surgical equipment with which the surgeon is familiar.

Outpatient procedures such as lumbar fusion offer many
benefits, he explained, noting reduced costs and increased patient
satisfaction. Most importantly, however, Dr. Husted asserted that such
procedures can be done safely.

“Infections have been studied and have been found to be
less prevalent in the ambulatory surgery setting,” he noted.

He acknowledged that some orthopaedists may be
uncomfortable moving to the outpatient setting for some procedures, but moving
outside one’s comfort zone is “how we move forward.”

His advice for those who want to transition to using
outpatient surgery centers for certain procedures is to select patients and
procedures carefully.

“I would start practicing sending patients home from the
hospital so that you can establish your own techniques and postoperative care,”
he advised.

Also, he added, “make sure you have a home health agency
that understands your protocols.”